Evaluation of interventions to improve inpatient hospital documentation within electronic health records: a systematic review.

Journal of the American Medical Informatics Association : JAMIA
Natalie WiebeHude Quan

Abstract

Despite the widespread and increasing use of electronic health records (EHRs), the quality of EHRs is problematic. Efforts have been made to address reasons for poor EHR documentation quality. Previous systematic reviews have assessed intervention effectiveness within the outpatient setting or paper documentation. The purpose of this systematic review was to assess the effectiveness of interventions seeking to improve EHR documentation within an inpatient setting. A search strategy was developed based on elaborated inclusion/exclusion criteria. Four databases, gray literature, and reference lists were searched. A REDCap data capture form was used for data extraction, and study quality was assessed using a customized tool. Data were analyzed and synthesized in a narrative, semiquantitative manner. Twenty-four studies were included in this systematic review. Owing to high heterogeneity, quantitative comparison was not possible. However, statistically significant results in interventions and affected outcomes were analyzed and discussed. Education and implementation of a new EHR reporting system were the most successful interventions, as evidenced by significantly improved EHR documentation. Heterogeneity of interventions, outcome...Continue Reading

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Citations

Nov 18, 2020·Journal of the American Medical Informatics Association : JAMIA·Min ChenRema Padman
Mar 9, 2021·International Journal of Medical Informatics·Lotta VirtanenTarja Heponiemi
Mar 9, 2021·Pain Management Nursing : Official Journal of the American Society of Pain Management Nurses·Aline Tsuma Gaedke NomuraMiriam de Abreu Almeida
Apr 1, 2021·Academic Psychiatry : the Journal of the American Association of Directors of Psychiatric Residency Training and the Association for Academic Psychiatry·Eduardo Constantino, Ruchi Vikas
Apr 13, 2021·Health Information Management : Journal of the Health Information Management Association of Australia·Christopher David Vetter, John H Kim
May 27, 2021·Revista latino-americana de enfermagem·Neurilene Batista de Oliveira, Heloísa Helena Ciqueto Peres

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